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1、溃疡性结肠炎的诊断和鉴别诊断溃疡性结肠炎的诊断和鉴别诊断Clinical PresentationClinical PresentationnIntestinal SymptomsIntestinal Symptomsn70%of patients with UC report 5 bowel movements during acute phases.nThe main reason for diarrhea is colonic inflammation,but bile acid and food malabsorption secondary to inflammation in th
2、e terminal ileum or the proximal small bowel can contribute to this symptom.nA history of surgical resections can be seminal in explaining symptoms.nAcute phases of UC almost always present with bloody diarrhea(“hematochezia”).nActive inflammatory anorectal lesions result in urgency of defecation an
3、d cramps around defecation(“tenesmus”).UC patients often complain of lower left quadrant pain.nExtraintestinal ManifestationsWafik El-Diery and David Metz,Section EditorsDiagnostics of Inflammatory Bowel DiseaseGastroenterology，2007;133:16701689肠外表现肠外表现(ExtraintestinalExtraintestinal manifestationsm
4、anifestations)n肠外表现包括：n皮肤黏膜表现(如口腔溃疡、结节性红斑和坏疽性脓皮病)n关节损害(如外周关节炎、脊柱关节炎等)n眼部病变(如虹膜炎、巩膜炎、葡萄膜炎等)、n肝胆疾病(如脂肪肝、原发性硬化性胆管炎、胆石症等)n血栓栓塞性疾病等。n Mendoza JL,Lana R,Taxonera C et al.Extraintestinal manifestations in inflammatory bowel disease:differences between Crohns disease and ulcerative colitis.Med.Clin.(Barc.)2
5、005;125:297300.并发症并发症(ComplicationsComplications)n并发症包括：n中毒性巨结肠（toxic megacolon）n肠穿孔n下消化道大出血n上皮内瘤变和癌变n钱家鸣,等.溃疡性结肠炎合并中毒性巨结肠六例及文献复习.中华内科杂志J.2012，51(9):694-697/nChow DK，Leong RW，Tsoi KK,et a1Longterm followup of ulcerative colitis in the Chinese populationAm J Gastroenterol，2009，104：647-654Serological
6、markersSerological markersnThe two most widely studied serological markers in inflammatory bowel disease in recent years have been p-ANCA and ASCA.The clinical utility of p-ANCA or ASCA testing in the diagnosis of inflammatory bowel disease,in patients with non-specific gastrointestinal symptoms,is
7、limited because of the varying seroprevalence of these antibodies in patients with inflammatory bowel disease and the inadequate sensitivity of the assays.nReese GE,Constantinides VA,Simillis C et al.Diagnostic precision of anti-Saccharomyces cerevisiae antibodies and perinuclear antineutrophil cyto
8、plasmic antibodies in inflammatory bowel disease.Am J Gastroenterol.2006(Oct);101(10):241022.尿白蛋白尿白蛋白n目的：探讨炎症性肠病患者尿中白蛋白的临床意义。n方法：对临床确诊的32例IBD患者（UC 27例，CD 5 例)在疾病的不同时期，用免疫放射比浊法测定尿中白蛋白，并结合临床 Harvey 和 Bradshaw 指数进行综合分析，选取25例健康人为正常对照。n结果：患者尿白蛋白活动期比缓解期明显增高（0.002），Harvey 和 Bradshaw 指数呈正相关（活动期 r=0.76,P0.00
9、1；静止期 r=0.73,P0.001）。患者尿中白蛋白明显高于正常人（活动期 P0.001,缓解期,P0.005）。n结论：患者尿中白蛋白可作为判断患者疾病活动情况的指标。n邓长生.炎症性肠病患者尿白蛋白的临床意义.武汉大学学报.2002，23(1)：88-89.FeFecal markerscal markersnCalprotectin(FCP),a heterocomplex of S100A8 and S100A9,is a calcium-binding protein with antimicrobial protective properties derived predomi
10、nately from neutrophils,and to a lesser extent,from monocytes and reactive macrophages.It constitutes approximately 5%of the total protein and up to 60%of the cytosolic protein in human neutrophils.As such,the fecal calprotectin concentration is proportional to the influx of neutrophils into the int
11、estinal tract,a hallmark of active IBD.nLactoferrin is an iron-binding glycoprotein identified in the secretions overlying most mucosal surfaces that interact directly with external pathogens,including saliva,tears,vaginal secretions,feces,synovial fluid,and mammalian breast milk.It is a major compo
12、nent of the secondary granules of polymorphonuclear neutrophils and is shown to be a primary factor in the acute inflammatory response.In the intestinal lumen,fecal lactoferrin levels quickly increase with the influx of neutrophils during inflammation.nSugi and colleagues investigated lactoferrin,po
13、lymorphonuclear neutrophil(PMN)elastase,and lysozyme together with myeloperoxidase in fecal material and whole-gut lavage fluid from IBD patients.nLanghorst J,Elsenbruch S,Mueller T et al.Comparison of 4 neutrophil-derived proteins in feces as indicators of disease activity in ulcerative colitis.Inf
14、lamm.Bowel Dis.2005;11:108591.钡剂灌肠钡剂灌肠n检查所见的主要改变为：n(1)黏膜粗乱和(或)颗粒样改变；n(2)肠管边缘呈锯齿状或毛刺样，肠壁有多发性小充盈缺损；n(3)肠管短缩，袋囊消失呈铅管样。CTCTUlcerative colitis with backwash ileitis.Axial CT enterographic sections show continuous involvement of the large bowel(white arrrows)and backwash ileitis(black arrow in b).Elsayes
15、KM，AIHawary MM，Jagdish J，et a1CT enterography：principles，trends，and interpretation of findingsRadiographics，2010，30：19551970结肠镜检查结肠镜检查Danese S，Fiocehi CUlcerative colitisN Engl J Med，2011365：1713 1725n结肠镜检查并活组织检查(后文简称活检)是UC诊断的主要依据。n结肠镜下UC病变多从直肠开始，呈连续性、弥漫性分布，表现为：n(1)黏膜血管纹理模糊、紊乱或消失，黏膜充血、水肿、质脆、自发或接触出血和
16、脓性分泌物附着，亦常见黏膜粗糙、呈细颗粒状；n(2)病变明显处可见弥漫性、多发性糜烂或溃疡；n(3)可见结肠袋变浅、变钝或消失以及假息肉、桥黏膜等。Typical endoscopic findingsTypical endoscopic findingsn n(A)UC with mild inflammation and reduced haustration,vascular transparency is missing.n(B)Moderate inflammation with reduced haustration.The mucosa is edematous,covered
17、with fibrin,and shows multiple erosions.n(C)Severe inflammation with inflammatory narrowing of the lumen through pseudopolyps.放大放大内内镜镜(Confocal microscopy)(Confocal microscopy)n n内镜下黏膜染色技术能提高内镜对黏膜病变的识别能力，结合放大内镜技术，通过对黏膜微细结构的观察和病变特征的判别，有助UC诊断，n姜泊，等放大内镜结合黏膜染色技术诊断溃疡性结肠炎附1 16例放大内镜形态分析现代消化及介入诊疗，2005，10：11
18、6118small-bowel capsule endoscopy(SBCE).small-bowel capsule endoscopy(SBCE).n Crohns disease and ulcerative colitis are lifelong diseases.Both diseases are marked by frequent relapses and patients often undergo repeated investigationsto define the extent of the disease,assess the severity of relapse
19、,or identify complications.nWhereas ulcerative colitis is a chronic inflammatory condition causing diffuse and continuous mucosal inflammation of the colon,Crohns disease is a heterogeneous entity comprised of several different phenotypes,but can affect the entire gastrointestinal tract.nThe use of
20、capsule endoscopy as a filter for pushandpull enteroscopy(PPE)is occasionally necessary in patients with established ulcerative colitis when the diagnosis is questioned,especially before surgery.n Capsule endoscopy can also direct the choice of route of PPE.SBCESBCEn nSubtle lesions as seen at small
21、-bowel capsule endoscopynBourreille A，Ignjatovic A，Aabakken L，et a1Role of smallbowel endoscopy in the management of patients with inflammatory bowel disease：an international OMED-ECCO consensusEndoscopy，2009，41：618637黏膜活检组织学检查n组织学可见以下主要改变。n活动期：(1)固有膜内弥漫性急慢性炎性细胞浸润，包括中性粒细胞、淋巴细胞、浆细胞和嗜酸粒细胞等，尤其是上皮细胞间中性粒
22、细胞浸润及隐窝炎，乃至形成隐窝脓肿；(2)隐窝结构改变：隐窝大小、形态不规则，排列紊乱，杯状细胞减少等；(3)可见黏膜表面糜烂，浅溃疡形成和肉芽组织增生。n缓解期：(1)黏膜糜烂或溃疡愈合；(2)固有膜内中性粒细胞浸润减少或消失，慢性炎性细胞浸润减少；(3)隐窝结构改变：隐窝结构改变可加重，如隐窝减少、萎缩，可见潘氏细胞化生(结肠脾曲以远)。nUC活检标本的病理诊断：活检病变符合上述活动期或缓解期改变，结合临床，可报告符合UC病理改变。宜注明为活动期或缓解期。如有隐窝上皮异型增生(上皮内瘤变)或癌变，应予注明。Riley SA,Mani V,Goodman MJ,et al.Microscop
23、ic activity in ulcerative colitis:what does it mean?Gut.1991;32:174178.Microscopic findings in biopsiesMicroscopic findings in biopsiesn n(D,E)Crypt abscess in UC.(F)Pseudopolyp formation.L,lymph follicle.nNikolaus S，Schreiber SDiagnostics of inflammatory bowel diseaseGastroenterology，2007，133：16701
24、689诊断要点n在排除其他疾病基础上，可按下列要点诊断：n(1)具有上述典型临床表现者为I临床疑诊(spicious)，安排进一步检查；n(2)同时具备上述结肠镜和(或)放射影像特征者，可临床拟诊(probable)；n(3)如再加上上述黏膜活检和(或)手术切除标本组织病理学特征者，可以确诊(definite)；n(4)初发病例如I临床表现、结肠镜及活检组织学改变不典型者，暂不确诊UC，应予随访(follow-up)。Lennard-Jones JE.Classification of inflammatory bowel disease.Scand J Gastroenterol.Suppl
25、.1989;170:26;discussion 1619.Diagnostic criterianVarious diagnostic classifications of IBD are available,including Mendeloffs criteria,the Lennard-Jones criteria,the international multicentre scoring system of the Organization Mondiale de Gastroenterologie(OMGE),and the diagnostic criteria of Japane
26、se Research Society on IBD.nModified Mendeloff criteria plus key points of the Lennard-Jones criteria,commonly used criteria,are presented here.nMyren J,Bouchier IA,Watkinson G,Softley A,Clamp SE,de Dombal FT.The OMGE multinational inflammatory bowel disease survey 19761986.A further report on 3175
27、cases.Scand J Gastroenterol.Suppl.1988;144:1119.鉴别诊断n1 1急性感染性急性感染性肠肠炎炎：各种细菌感染，如志贺菌、空肠弯曲菌、沙门菌、产气单孢菌、大肠埃希菌、耶尔森菌等。常有流行病学特点(如不洁食物史或疫区接触史)，急性起病常伴发热和腹痛，具自限性(病程一般数天至1周，不超过6周)；抗菌药物治疗有效；粪便检出病原体可确诊。n2 2阿米巴阿米巴肠肠病病n3 3肠肠道血吸虫病道血吸虫病n4 4其他其他：肠结核、真菌性肠炎、抗生素相关性肠炎(包括假膜性肠炎)、缺血性结肠炎、放射性肠炎、嗜酸粒细胞性肠炎、过敏性紫癜、胶原性结肠炎、白塞病、结肠息肉病、
28、结肠憩室炎以及人类免疫缺陷病毒(HIV)感染合并的结肠病变应与本病鉴别。DiDifferentiate diagnosisfferentiate diagnosisn DiDifferentiate diagnosisfferentiate diagnosisn 夏冰，等.缺血性结肠炎与溃疡性结肠炎的临床鉴别诊断.胃肠病学.2010，15(11)：681-683.International Study Group for Behcets disease.Criteria for theInternational Study Group for Behcets disease.Criteria for thediagnosis of diagnosis of Behcets diseaseBehcets disease.Lancet 1990;335:10781080.Lancet 1990;335:10781080.n 感谢您的观看！